Evaluation of the SAMe-TT2R2 score to predict the quality of anticoagulation control in patients with venous thromboembolism treated with vitamin K antagonists: Findings from the RIETE registry

BACKGROUND

The time in therapeutic range (TTR) of patients with venous thromboembolism (VTE) treated with vitamin K antagonists (VKA) is usually below recommended, leading to higher frequency of vascular events, bleeding and mortality. The SAMe-TT2R2 prediction score discriminates those patients with high or low probability of obtaining poor INR control and its use is recommended in patients with atrial fibrillation. Its usefulness has been evaluated in patients with VTE, with conflicting results.

METHOD

We included consecutive patients enrolled in Registro Informatizado Enfermedad TromboEmbolica (RIETE), a prospective multicenter VTE registry, treated with VKA for >90 days and a minimum of 3 INR determinations. We analyzed the relationship between the SAMe-TT₂R₂ score and TTR, determined by the Rosendaal method and by the percentage of INR determinations (after excluding the first month). A ROC curve was calculated considering a cut-off point of TTR ≥65% for good anticoagulation control.

RESULTS

3893 patients were included and classified in high (1411 patients) or low (2482 patients) probability of obtaining poor INR control according to the total score obtained (0-1 points versus 2 points, respectively). TTR, calculated by direct method and Rosendaal method, was 51.2 (±23.4) and 55.4 (±25.9) in the high probability group; and 54.4 (±23.0) and 58.2 (±25.6) in the low probability group, respectively (p < 0.001 for both comparisons). The outcomes were similar between groups. The predictive capacity of the SAMe-TT2R2 score showed an area under the ROC curve of 0.54 (CI 95% 0.52-0.56) and 0.53 (CI 95% 0.51-0.55).

CONCLUSIONS

In patients with VTE treated with VKA, the SAMe-TT2R2 score discriminated those patients with high probability of obtaining poor INR control, but with a low predictive capacity. Further studies are required to assess the usefulness of the score in clinical decision-making.

Automatic or manual arterial path for the ankle-brachial differences pulse wave velocity

An automated method for measuring arterial path length with devices that determine pulse wave velocity (PWV) in peripheral arteries is frequently applied. We aimed to compare arterial path length measurements based on mathematical height-based formulas with those measured manually and to assess whether the ankle-brachial difference (abD-PWV) measured with the VOPITB device is comparable to that obtained by manual measurements. In 245 patients, a metric measuring tape was used to determine the arterial path length from the suprasternal notch to the midpoint of the VOPITB cuffs wrapped around the extremities, and the results were compared with those obtained with height-based formulas. We examined the relationship between the abD-PWV measured with both methods. The arterial path length measured manually was shorter than that calculated automatically by 5 ± 2 and 30 ± 4 cm—of 13% and 21% for the arms and legs, respectively (difference of 13% and 21%). As a result, the abD-PWV calculated with the automatic method was greater (automatic abD-PWV vs. manual: 462 ± 90 vs. 346 ± 79 cm/s). The Blant Altman plot showed a percentage error of: 15,2%, 7,5% and 17,3% for heart-brachial, heart-ankle length and abD-PWV respectively. In conclusion there were significant differences between manual and automated arterial length measurements and it translates into difference abD-PWV calculate from both methods. However, the Bland-Alman plot showed that abD-PWV was comparable for both techniques. The advantages of height-based formulas for the calculation of arterial path lengths suggest that they may be the recommended method for measuring the abD-PWV.

Clinical Characteristics and Outcomes of Patients with Lung Cancer and Venous Thromboembolism

Background  The natural history of patients with lung cancer and venous thromboembolism (VTE) has not been consistently evaluated.

Methods  We used the RIETE (Registro Informatizado Enfermedad TromboEmbólica) database to assess the clinical characteristics, time course, and outcomes during anticoagulation of lung cancer patients with acute, symptomatic VTE.

Results  As of May 2017, a total of 1,725 patients were recruited: 1,208 (70%) presented with pulmonary embolism (PE) and 517 with deep vein thrombosis (DVT). Overall, 865 patients (50%) were diagnosed with cancer <3 months before, 1,270 (74%) had metastases, and 1,250 (72%) had no additional risk factors for VTE. During anticoagulation (median, 93 days), 166 patients had symptomatic VTE recurrences (recurrent DVT: 86, PE: 80), 63 had major bleeding (intracranial 11), and 870 died. The recurrence rate was twofold higher than the major bleeding rate during the first month, and over threefold higher beyond the first month. Fifty-seven patients died of PE and 15 died of bleeding. Most fatal PEs (84%) and most fatal bleeds (67%) occurred within the first month of therapy. Nine patients with fatal PE (16%) died within the first 24 hours. Of 72 patients dying of PE or bleeding, 15 (21%) had no metastases and 29 (40%) had the VTE shortly after surgery or immobility.

Conclusion  Active surveillance on early signs and/or symptoms of VTE in patients with recently diagnosed lung cancer and prescription of prophylaxis in those undergoing surgery or during periods of immobilization might likely help prevent VTE better, detect it earlier, and treat it more efficiently.

Multivariate analysis for coronary heart disease in heterozygote familial hypercholesterolemia patients

AIM

rs599839 polymorphism has been related with low levels of cholesterol and reduced coronary heart disease (CHD).

METHODS

We investigated the frequency of this polymorphism in patients with heterozygous familial hypercholesterolemia (HeFH) in the Spanish familial hypercholesterolemia cohort, 230 with and 202 without CHD. Results & discussion: A lower G-allele prevalence was observed in HeFH patients with CHD with respect to controls, 35 versus 45%, respectively (p = 0.029), suggesting a protective effect. However, it was found that there was no association between rs599839 alleles and CHD in the multivariate analysis.

CONCLUSION

The frequency of the protective G-allele of the rs599839 polymorphism was lower in HeFH patients with CHD compared with those HeFH patients without CHD. However, its role in HeFH may be masked by very high levels of cholesterol.

Clinical outcome of patients with venous thromboembolism and renal insufficiency

There is little information on the clinical outcome of patients with venous thromboembolism and renal insufficiency. RIETE is an ongoing, prospective registry of consecutive patients with acute, objectively confirmed, symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE). In this analysis we analyzed the three-month outcome in patients with creatinine clearance (CrCl) <30 ml/min. As of March 2007, 1,037 of the 18,251 (5.7%) patients enrolled in RIETE had CrCl <30 ml/min. During the three-month study period these patients had an increased incidence of fatal bleeding, fatal PE, and overall death compared to those with CrCl >30 ml/min. Of the 579 patients presenting with clinically overt PE, 52 (9.0%) died of the initial PE, 13 (2.2%) of recurrent PE, and nine (1.6%) died of bleeding complications. During the first 15 days of therapy the 10% incidence of fatal PE was 10-fold their 1.0% of fatal bleeding. From day 16 to 90, the 1.0% rate of fatal PE was not significantly higher than the 0.5% of fatal bleeding. Of the 458 DVT patients with CrCl <30 ml/min, 14 (3.1%) had fatal bleeding and only one (0.2%) died of PE. In patients with CrCl <30 ml/min presenting with clinically overt PE the main threat is PE itself. On the contrary, in those with DVT the main threat is bleeding.

Raised Fibrinogen Levels and Outcome in Outpatients With Peripheral Artery Disease

The influence of raised fibrinogen levels on outcome in stable outpatients with peripheral arterial disease (PAD) has not been consistently investigated. We used data from the Factores de Riesgo y ENfermedad Arterial (FRENA) registry to compare ischemic events, major bleeding, and mortality in stable outpatients with PAD, according to their baseline plasma fibrinogen levels. Of 1363 outpatients with PAD recruited in FRENA, 558 (41%) had fibrinogen levels >450 mg/100 mL. Over 18 months, 43 patients presented with acute myocardial infarction, 37 had an ischemic stroke, 51 underwent limb amputation, 19 had major bleeding, and 90 died. Compared to patients with normal levels, those with raised fibrinogen levels had an over 2-fold higher rate of ischemic stroke (rate ratio [RR]: 2.30; 95% confidence interval [CI]: 1.19-4.59), limb amputation (RR: 2.58; 95% CI: 1.46-4.67), or death (RR: 2.27; 95% CI: 1.49-3.51) and an over 3-fold higher rate of major bleeding (RR: 3.90; 95% CI: 1.45-12.1). On multivariate analysis, patients with raised fibrinogen levels had an increased risk of developing subsequent ischemic events (hazard ratio [HR]: 1.61; 95% CI: 1.11-2.32) and major bleeding (HR: 3.42; 95% CI: 1.22-9.61). Stable outpatients with PAD and raised plasma fibrinogen levels had increased rates of subsequent ischemic events and major bleeding.

Recurrence of venous thromboembolism in patients with recent gestational deep vein thrombosis or pulmonary embolism: Findings from the RIETE Registry

INTRODUCTION

The aim of this study was to investigate the recurrence rate of venous thromboembolism (VTE) and the prevalence of major bleeding or death in patients with previous VTE in pregnancy and puerperium. Risk factors for VTE recurrence were also assessed.

MATERIALS AND METHODS

We evaluated a cohort of patients enrolled in the international, multicenter, prospective Registro Informatizado de la Enfermedad Trombo-Embólica (RIETE) registry with objectively confirmed VTE.

RESULTS

In the registry, 607 women were presenting with VTE that occurred during pregnancy or puerperium. The 2-year VTE recurrence rate was 3.3% (CI: 95 1.5-5.0%) and the recurrent VTE incidence rate was 2.28events/100 patients-year. Among the 16 cases of VTE recurrence 11 cases appeared during drug treatment while only five cases were diagnosed after therapy discontinuation. No significant difference was found in treatment duration among these two subgroups of VTE recurrence cases and women without recurrence. Furthermore, the use of thrombolytics and inferior vena cava filter in initial treatment was associated to an increased risk of VTE recurrence.

CONCLUSIONS

The current study provides new insights on VTE recurrence rate in patients with deep vein thrombosis (DVT) or pulmonary embolism (PE) that occurred in pregnancy or postpartum period. These findings can contribute to risk assessment of thrombotic burden, thereby allowing for better decision making regarding antithrombotic management in this clinical setting.

Anemia and Outcome in Outpatients With Peripheral Artery Disease

The influence of anemia on outcome in stable outpatients with peripheral artery disease (PAD) has not been consistently investigated. We used data from the Factores de Riesgo y ENfermedad Arterial (FRENA) Registry to compare ischemic events and mortality rates in stable outpatients with symptomatic PAD and anemia. Of 1663 patients with PAD, 208 (12.5%) had anemia. Over 18 months, patients with anemia had a higher rate of myocardial infarction (MI; rate ratio [RR]: 2.10; 95% confidence interval [CI]: 1.04-3.99), limb amputation (RR: 2.98; 95%CI: 1.70-5.05), and higher mortality (RR: 3.58; 95%CI: 2.39-5.28) than those without anemia. The rates of ischemic stroke (RR: 0.75; 95%CI: 0.23-1.93) and major bleeding (RR: 0.93; 95%CI: 0.15-3.51) were similar. On multivariable analysis, anemia was associated with an increased risk to die (hazard ratio [HR]: 2.32; 95%CI: 1.53-3.50) but not to develop MI (HR: 1.49; 95%CI: 0.73-3.05) or to have limb amputation (HR: 1.49; 95%CI: 0.86-2.59). In stable outpatients with PAD, anemia was associated with increased mortality but not with an increased rate of subsequent ischemic events or major bleeding.

Cilostazol and outcome in outpatients with peripheral artery disease

BACKGROUND

Cilostazol increases the walking distance in patients with intermittent claudication, but there is scarce evidence of any effect on the risk for subsequent ischemic events, bleeding or death.

PATIENTS AND METHODS

We used data from the FRENA Registry to compare the clinical outcome in stable outpatients with intermittent claudication, according to the use of cilostazol.

RESULTS

As of January 2013, 1,317 patients with intermittent claudication were recruited in FRENA, of whom 191 (14.5%) received cilostazol. Over a mean follow-up of 18months, 39 patients developed myocardial infarction, 23 ischemic stroke, 20 underwent limb amputation, 15 had major bleeding and 70 died. There were no significant differences in the rate of subsequent ischemic events, major bleeding or death between patients receiving or not receiving cilostazol. On multivariate analysis, the use of cilostazol had no influence on the risk for subsequent myocardial infarction (hazard ratio [HR]: 0.97; 95% CI: 0.33-20.8), ischemic stroke (HR: 1.46; 95% CI: 0.48-4.43), limb amputation (HR: 0.34; 95% CI: 0.04-20.6), major bleeding (HR: 1.52; 95% CI: 0.33-7.09) or death (HR: 0.90; 95% CI: 0.40-20.0).

CONCLUSIONS

In stable outpatients with intermittent claudication, the use of cilostazol was not associated with increased rates of subsequent ischemic events, major bleeding or death.

Glucose control and outcome in patients with stable diabetes and previous coronary, cerebrovascular or peripheral artery disease. Findings from the FRENA Registry

AIM

The aim of this study was to address the controversy over the influence of intensive glucose control on the risk for cardiovascular events in patients with Type 2 diabetes.

METHODS

FRENA is an ongoing registry of stable outpatients with symptomatic coronary artery disease, cerebrovascular disease or peripheral artery disease. We compared the incidence of subsequent ischaemic events (myocardial infarction, stroke or critical limb ischaemia) in patients with Type 2 diabetes and mean HbA(1c) levels < 7.0% (< 53 mmol/mol) vs. those with HbA(1c) levels > 7.0% (> 53 mmol/mol).

RESULTS

Of 974 patients with Type 2 diabetes, 480 (49%) had mean HbA(1c) levels < 7% (< 53 mmol/mol). Over a mean follow-up of 14 months, 126 patients (13%) had subsequent ischaemic events: myocardial infarction (43), stroke (29) and critical limb ischaemia (64). The incidence of subsequent ischaemic events was significantly lower in patients with mean HbA(1c) levels < 7.0% (< 53 mmol/mol) than in those with HbA(1c) levels > 7.0% (> 53 mmol/mol) (8.6 vs. 14 per 100 patient-years; rate ratio 0.6; 95% CI 0.4-0.9). These differences persisted after adjusting for potential confounders. However, this better outcome was only found in patients presenting with coronary artery disease (rate ratio 0.4; 95% CI 0.2-0.8), not in those with cerebrovascular disease (rate ratio 0.9; 95% CI 0.4-2.0) or peripheral artery disease (rate ratio 0.8; 95% CI 0.5-1.3). Patients with mean HbA(1c) levels < 7.0% (< 53 mmol/mol) also had a lower mortality (rate ratio 0.6; 95% CI 0.3-0.99).

CONCLUSIONS

In secondary prevention, patients with diabetes and HbA(1c) levels < 7.0% (< 53 mmol/mol) had a lower incidence of subsequent ischaemic events and a lower mortality than those with HbA(1c) levels > 7.0% (> 53 mmol/mol). These differences appeared only in patients with coronary artery disease.

Concomitant use of proton pump inhibitors and clopidogrel in patients with coronary, cerebrovascular, or peripheral artery disease in the factores de Riesgo y ENfermedad Arterial (FRENA) registry

BACKGROUND

Among patients receiving clopidogrel for coronary artery disease, concomitant therapy with proton pump inhibitors (PPIs) has been associated with an increased risk for recurrent coronary events.

PATIENTS AND METHODS

Factores de Riesgo y ENfermedad Arterial (FRENA) is an ongoing, multicenter, observational registry of consecutive outpatients with coronary artery disease, cerebrovascular disease, or peripheral artery disease. We retrospectively examined the influence of concomitant use of PPIs on outcome in patients receiving clopidogrel.

RESULTS

As of March 2009, 1222 patients were using clopidogrel: 595 had coronary artery disease, 329 cerebrovascular disease, and 298 had peripheral artery disease. Of these, 519 (42%) were concomitantly using PPIs. Over a mean follow-up of 15 months, 131 patients (11%) had 139 subsequent ischemic events: myocardial infarction 44, ischemic stroke 40, and critical limb ischemia 55. Seventeen of them (13%) died within 15 days of the subsequent event. PPI users had a higher incidence of myocardial infarction (rate ratio, 2.5; 95% confidence interval [CI], 1.3-4.8), ischemic stroke (rate ratio, 1.9; 95% CI, 1.03-3.7), and a nonsignificantly higher rate of critical limb ischemia (rate ratio, 1.6; 95% CI, 0.95-2.8) than nonusers. On multivariate analysis, concomitant use of clopidogrel and PPIs was independently associated with an increased risk for subsequent ischemic events both in the whole series of patients (hazard ratio, 1.8; 95% CI, 1.1-2.7) and in those with cerebrovascular disease or peripheral artery disease (hazard ratio, 1.5; 95% CI, 1.01-2.4).

CONCLUSIONS

In patients with established arterial disease, concomitant use of PPIs and clopidogrel was associated with a nearly doubling of the incidence of subsequent myocardial infarction or ischemic stroke. This higher incidence persisted after multivariate adjustment.

Adverse drug reactions in internal medicine units and associated risk factors

OBJECTIVES

This study was designed to assess the prevalence of adverse drug reactions (ADRs) in the internal medicine wards of two teaching hospitals, identify the most common ADRs, the principal medications involved, and determine the risk factors implicated in the occurrence of such ADRs.

METHODS

All admissions over 10 weeks were followed prospectively using an intensive drug surveillance method to identify ADRs. Clinical laboratory data, the drug prescribed, and ADRs were taken into consideration. Status of nutrition, liver and kidney function at admission, and ADR time were determined. In order to assess drug interactions a software package was used.

RESULTS

A total of 405 patients were evaluated, 126 patients (31%) had 128 ADRs, 122 ADRs occurred during hospitalization. Two ADR-related deaths were observed during the study. Reactions affecting the gastrointestinal tract, skin, and hematological system were among the most frequent ADRs. For ADRs observed during admission predictors of its occurrence in a multivariate regression model were: OR (95% CI); more than 12 days' hospitalization: 2.11(1.27-3.47), any drug interaction: 9.33 (5.12-17) and acute change in estimated glomerular filtration rate over admission >20%: 2.46 (1.45-4.2). Worsening of renal function or drug interaction was observed in nine of the ten ADRs. Age, sex, nutrition, and number of drugs used were not related to ADRs.

CONCLUSION

A significant prevalence of ADRs was found among hospitalized patients. Duration of hospital admission, changes in renal status during hospitalization and drug interactions seem to be important risk factors for ADRs.

Clinical outcome of patients with venous thromboembolism and renal insufficiency. Findings from the RIETE registry

There is little information on the clinical outcome of patients with venous thromboembolism and renal insufficiency. RIETE is an ongoing, prospective registry of consecutive patients with acute, objectively confirmed, symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE). In this analysis we analyzed the three-month outcome in patients with creatinine clearance (CrCl) <30 ml/min. As of March 2007, 1,037 of the 18,251 (5.7%) patients enrolled in RIETE had CrCl <30 ml/min. During the three-month study period these patients had an increased incidence of fatal bleeding, fatal PE, and overall death compared to those with CrCl >30 ml/min. Of the 579 patients presenting with clinically overt PE, 52 (9.0%) died of the initial PE, 13 (2.2%) of recurrent PE, and nine (1.6%) died of bleeding complications. During the first 15 days of therapy the 10% incidence of fatal PE was 10-fold their 1.0% of fatal bleeding. From day 16 to 90, the 1.0% rate of fatal PE was not significantly higher than the 0.5% of fatal bleeding. Of the 458 DVT patients with CrCl <30 ml/min, 14 (3.1%) had fatal bleeding and only one (0.2%) died of PE. In patients with CrCl <30 ml/min presenting with clinically overt PE the main threat is PE itself. On the contrary, in those with DVT the main threat is bleeding.

Efecto de la atorvastatina sobre los valores del propéptido natriurético cerebral N-terminal en pacientes con hipercolesterolemia con hipertensión arterial y sin ella

BACKGROUND AND OBJECTIVE

N-terminal pro-brain natriuretic peptide (NT-proBNP) is a useful predictor of cardiovascular events in patients without clinical evidence of cardiovascular disease. It is unknown if the cardiovascular risk factors control can modify these levels. We studied if atorvastatin treatment decrease NT-proBNP levels in hypercholesterolemic subjects, with and without hypertension.

PATIENTS AND METHOD

It was an open, prospective study in 39 patients with hypercholesterolemia without clinical evidence of cardiovascular disease. 15 (38.5%) had hypertension. Blood samples were collected initially and 12 and 24 weeks after beginning treatment with 20 mg of atorvastatin.

RESULTS

The median age was 54 years, and 41% were males. NT-proBNP (pg/ml) values were: 193 (294) at baseline; 141 (211) (p < 0.05) after 12 weeks therapy, and 89 (130) (p < 0.01) at 24 weeks. In hypertensive patients value changed from: 275 (388) at baseline, 196 (290) (p < 0.05) and 112 (124) (p < 0.001) after 12 and 24 weeks treatment. And the levels in normotensives patients were: 137 (198) at baseline, 103 (129) (p = NS), and 74 (135) (p < 0.001) at 12 and 24 weeks after treatment with atorvastatin. We didn't find any correlations between the percentage decrease in NT-proBNP levels, and change of total cholesterol, systolic blood pressure, C reactive protein, or nitrites/nitrates blood levels, at 12, and 24 weeks compared to baseline levels.

CONCLUSIONS

In middle-aged hypercholesterolemic patients, without evidence of cardiovascular disease, atorvastatin therapy decrease NT-proBNP blood levels, in both hypertensive and normotensives subjects.